2Case Study QuizA baseball player waiting his turn on deck receives a direct blow to the upper row of teeth by a baseball bat being swung by the person next to him.Short list of injuriesTxReferral21
3Case Study QuizA 14 YO basketball player is struck in the nose by an opponent's elbow while grabbing a rebound. He runs to the bench holding his nose, which is now pouring blood.This is what you see after stopping the bleeding.(procedures to stop)Short list of injuriesEvaluate, TXReferral21
8Soft Tissue Eye Ear TMJ joint Mandible and temporal bone Ligaments Joint capsuleMeniscus between the condyle of mandible and articular surface of temporal bone (concave articular fossa and convex articular eminence)
9Nasal soft tissue Cartilage of the nose external = lateral and alar cartilageinternal = quadrangular cartilage and membranous septum which separates it from the alar cartilage distallySeptum divides into 2 passages (2-4 mm)Proximal half is skeletal - vertical plate of ethmoid, vomer, & minimal portions of palatine and maxillary bones
19TxDepends on the size of the defect and the amount of entrapment.In the absence of diplopia, even in extreme up gaze, no treatment may be indicated but is usually offered in large defects where there is concern about prolapse of orbital fat and subsequent enophthalmos or entrapped tissue with persisting vertical diplopia.Surgical repair is best carried out within 10 days of the injury.
21If zygomatic arch may see dimpling with bone intact Evaluation & TxcrepitusIf zygomatic arch may see dimpling with bone intactIf unstable repair right awayLift up and out as it snaps back in (intra or extra orally)
23PathophysiologyFrontal force - Causes damage ranging from simple fracture of the nasal bones to flattening of the entire noseLateral force - May depress only one nasal bone; with sufficient force, both bones may be displaced; can cause severe septal displacement, which can twist or buckle the nose; septal fragments may interlock, creating difficulty in reductionSuperior-directed force (from below) - Rarely occurs; may cause severe septal fractures and dislocation of the quadrangular cartilage
24Epistaxis – Common in nasal fractures due to mucosal disruption Clinical FindingsEpistaxis – Common in nasal fractures due to mucosal disruptionChange in nasal appearanceNasal airway obstructionInfraorbital ecchymosisfor CSF fluid
25Septal HematomaPossibility of septal hematoma – gentle palpation reveals it is soft and compressibleneedle aspiration or vertical mucosal incision and drainagefirm anterior layered gauze pack to keep the septal mucosa pressed firmly against the cartilage.
28EvaluationX-rays are controversial - studies have shown that radiographs are not helpful in the diagnosis or management of nasal fractures. Old fractures, vascular markings, and suture lines can lead to false-positive results.CT scan is more useful to assess for other associated injuries, as well as extent of nasal injury. Because the nose occupies such a prominent and accessible position, careful examination is possible and may obviate any need for radiographic study.Photographs are useful for documentation and for comparison with pre-injury photos.
29TxElevation of head and cold compressesClosed or open reduction within 2 weeks of the fracture. The potential for optimal results lies in the reduction of the fracture within the first several hours following the injury, before significant edema has appeared. If this window has passed, subsequent reassessment of the injury is advisable, with correction planned for approximately 7 days following the injury.
30TxWaiting at least 6 months to perform surgery allows fractures to stabilize and wounds to heal if Fx identified after significant bony healing has occurred.Post surgery – splints in place for 7-10 days when necessary.Simple closed reduction requires no packing.If packs used - continue taking antibiotics to avoid toxic shock.The use of cold compresses for 1-2 days reduces edema and discomfort.
33LeFort Classification LeFort I - transmaxillary Fx runs between the maxillary floor and the orbital floor. The floating fragment will be the lower maxilla with the maxillary teethLeFort II - described as a pyramidal Fx because of its shape. Involves maxilla & nasal (MOI = downward blow to nasal area)
34LeFort Classification LeFort III - Referred to as the craniofacial disassociation as the unstable fragment is the entire face. (A/P translation)It involves the maxilla, bony orbit and nasal bone as well as soft tissueMOI is a considerable force which also involves injury to the skull and brainUse of CT scan to diagnose
35Open or closed reduction Incision and the use of plates or screws TxOpen or closed reductionIncision and the use of plates or screwsseptal damagevitals
36Smash Fx Severe comminution of the face Underlying skull injury Individual is often in unstable condition with other injuries involved
42Ear Injuries Laceration of the external ear Auricular hematoma Otitis Externa - infection of external earTympanic membrane rupturesudden change of air pressure caused by blunt traumaDirect blunt trauma
45Avoid cold or warm liquids Check for exposure of pulp TxAvoid cold or warm liquidsCheck for exposure of pulpDo not try to locate the chipped areaRefer to dentist the next dayTooth can be capped or bonded for cosmetic purposesfor tooth vitality periodically
46Fx – Class III, IVSplint, root canal, removal of tooth
50Replant immediately if possible (within 30 min) Transport medium TxReplant immediately if possible (within 30 min)Transport mediumA. Hank's Balanced Salt Solution (H.B.S.S.)B. Milk – but could sour over timeC. SalineD. Saliva (buccal Vestibule)If none of the above is readily available, use waterNever transport in gauze
51Management of root surface 1. Keep the tooth moist at all times.2. Do not handle the root surface (hold tooth by the crown).3. Do not scrape or brush the root surface or remove the tip of the root.4. If the root appears clean, replant as is after rinsing with saline.5. If the root surface is contaminated, rinse with H.B.S.S. or saline If persistent debris remains on root surface, gently use cotton pliers to remove remaining debris and/or gently brush off debris with a wet sponge.
52Management of the Socket 1. Gently aspirate without entering the socket. If a clot is present, use light irrigation with saline. 2. Do not curette the socket.3. Do not vent socket.4. Do not make a surgical flap unless bony fragments prevent replantation.5. If the alveolar bone is collapsed and prevents replantation, carefully insert a blunt instrument into the socket to reposition the bone to its original position.6. After replantation, manually compress (if spread apart) facial and lingual bony plates.
53Suture soft tissue and splint 1. use orthodontic brackets with passive arch wire. Suture in place only if alternative splinting methods are unavailable. (circumferential wire splints are contraindicated.)2. Splint should remain in place for 7-10 days; however, if tooth demonstrates excessive mobility, splint should be replaced until mobility is within acceptable limits.3. Bony fractures resulting in mobility usually require longer splinting periods (2-8 weeks).4. Home care during splinting period: no biting on splint, soft diet, good oral hygiene
54Prevention and Protection – Molded Mouthguards Impression of mouth, thermoplastic material adapted over cast
55Laboratory Pressure Laminated Mouthguard Laminate 2-3 layers of EVA – use of high heat & pressure